Hypotension Requiring Vasopressor Support After Endovascular Thrombectomy: Predictors and Neurological Consequences

Background/Objectives: Endovascular thrombectomy (EVT) has transformed the treatment of acute ischaemic stroke due to large-vessel occlusion, yet peri-procedural haemodynamic instability may compromise penumbral perfusion and neurological recovery. We assessed the frequency, determinants and clinical consequences of post-procedural hypotension after EVT. Methods: We retrospectively reviewed 201 consecutive adults who underwent endovascular thrombectomy for anterior-circulation large-vessel occlusion at a single tertiary centre over a period of eight years, from 1 January 2017 to 31 January 2025. Post-procedural hypotension was defined as hypotension requiring initiation of a continuous noradrenaline infusion within 24 h of the procedure. Comorbidities, anaesthetic modality (general anaesthesia [GA] or conscious sedation [CS]), National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores, and in-hospital mortality were recorded. Logistic regression identified independent predictors of hypotension. Results: Fifty-five patients (27.4%) developed post-procedural hypotension. They presented with more severe strokes (NIHSS 16.0 ± 5.0 vs. 13.7 ± 5.0; p = 0.002), had higher NIHSS scores at day 2 (14.0 ± 6.9 vs. 9.4 ± 6.7; p < 0.001) and day 7 (p = 0.003), and displayed markedly higher in-hospital mortality (50.9% vs. 20.5%; p < 0.001). In an ordinal analysis of the day 7 modified Rankin Scale with death coded as 6, hypotension was associated with a shift towards greater disability (common OR 2.57, 95% CI 1.40-4.72; p = 0.002). In an exploratory model, each additional 10 min of door-to-groin time was independently associated with hypotension (adjusted OR 1.10, 95% CI 1.03-1.18; p = 0.003). Independent predictors of hypotension were baseline NIHSS (adjusted OR 1.11 per point, 95% CI 1.04-1.19; p = 0.003) and active malignancy (adjusted OR 2.90, 95% CI 1.04-8.09; p = 0.042). Hypotension occurred with similar frequency under GA and CS (28.6% vs. 24.6%; adjusted OR 1.12, 95% CI 0.54-2.34; p = 0.766). Conclusions: Post-EVT hypotension is common and associated with poorer early neurological recovery and a more than two-fold higher in-hospital mortality rate. Its independent predictors were baseline stroke severity and active malignancy. Patients with severe stroke or active cancer may warrant intensified haemodynamic surveillance after thrombectomy. Procedural delay emerged as the only modifiable predictor identified and warrants prospective evaluation.